MEDICARE: CHARLES BLONS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP4351	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	295L6BL	OTHER	MN	BLUE CROSS BLUE SHIELD
2	30247-02	OTHER	MN	PREFERRED ONE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326090317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES BLONS, PLLC

Provider Business Mailing Address
First Line	:	9001 E BLOOMINGTON FWY
Second Line	:	SUITE 139
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-3435
Country	:	US
Telephone Number	:	952-881-6797
Fax Number	:	952-881-2028

Provider Business Practice Location Address
First Line	:	9001 E BLOOMINGTON FWY
Second Line	:	SUITE 139
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-3435
Country	:	US
Telephone Number	:	952-881-6797
Fax Number	:	952-881-2028

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES RODERICK BLONS
Credential	:	PH.D., L.P.
Telephone Number	:	952-881-6797

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/02/2010

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